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New addition to ADA Code of Conduct provides guidance in response to pandemic

CEBJA: Dentists should balance ethical obligations to patient, public at large

December 14, 2020

By David Burger

Dentists have ethical obligations to not only provide care for patients but also serve the public at large, especially during a public health crisis like the COVID-19 pandemic, according to a new advisory opinion approved by the ADA Council on Ethics, Bylaws and Judicial Affairs in late November.

The advisory opinion is included in the updated ADA Principles of Ethics and Code of Professional Conduct.

 Dr. Robert Wilson
Dr. Wilson
Titled “Elective and Non-Emergent Procedures during a Public Health Emergency,” the advisory opinion provides guidance on the analysis that needs to be performed during a widespread health emergency that is aimed at balancing the ethical obligations a dentist owes an individual patient and the public at large.

As was experienced during the early days of the pandemic last spring, those obligations may be in conflict, said Robert Wilson, D.D.S., chair of the council.

“The early stages of the COVID-19 pandemic presented public health risks that were readily apparent to the dental profession and the ADA,” Dr. Wilson said. “It was clear that our ethical obligations to the public at large gained greater importance than perhaps any time in the modern history of our profession. The pandemic forced dentists to shift their attention from the patient in our operatory to the entire community while never neglecting the best interest of our patients.”

Dr. Wilson continued to emphasize that while the profession’s response to the pandemic may have temporarily shifted the balance towards the public at large, it does not mean that dentists should ever abandon the interest of their patients.

“The objectives of reducing the risk of transmission by promoting social distancing, conserving scarce PPE resources and reducing pressure on hospital emergency departments became the main strategy of the response of our profession to the pandemic,” Dr. Wilson said. “With regard to the pandemic, prioritizing the public at large was also for the benefit of the patient … by promoting social distancing to reduce the risk of transmission. Further, this allowed an opportunity for dental practices and the profession to refine infection control measures and institute engineering modifications to enhance the safety measures we apply to the delivery of care to the individual patients.”

During the pandemic, the profession was asked to temporarily defer elective procedures while continuing to provide emergency care, Dr. Wilson said, and it was up to the dentist, in consultation with the patient, to determine what care could be deferred without undue risk of harm to the individual patient compared to the risk to the patient and the community at large.

“Any attempt to provide guidance on what constitutes a dental emergency should always include the reality that it is the dentist’s responsibility to weigh all of the pertinent factors and provide the appropriate response to each situation,” Dr. Wilson said. “In this case, the demands of an appropriate response to a pandemic that has touched the life of every person in our country and the entire world has required our profession to evaluate our ethical obligations in a novel manner.”

Advisory opinions allow the Code to be an evolving document, Dr. Wilson said, while still remaining true to its bedrock principles.

“The agility provided by advisory opinions allows the core principles of the Code to remain relevant and steadfast,” he said.

The full text of the new advisory opinion follows:
3.A.1. ELECTIVE AND NON-EMERGENT PROCEDURES DURING A PUBLIC HEALTH EMERGENCY.
Dentists have ethical obligations to provide care for patients and also serve the public at large. Typically, these obligations are interrelated. Dentists are able to provide oral health care for patients according to the patient’s desires and wishes, so long as the treatment is within the scope of what is deemed acceptable care without causing the patient harm or impacting the public. During public health crises or emergencies, however, the dentist’s ethical obligation to the public may supersede the dentist’s ethical obligations to individual patients. This may occur, for example, when a communicable disease causes individual patients who undergo treatment and/or the public to be exposed to elevated health risks. During the time of a public health emergency, therefore, dentists should balance the competing ethical obligations to individual patients and the public. If, for example, a patient requests an elective or non-emergent procedure during a public health crisis, the dentist should weigh the risk to the patient and the public from performing that procedure during the public health emergency, postponing such treatment if, in the dentist’s judgment, the risk of harm to the patient and/or the public is elevated and cannot be suitably mitigated. If, however, the patient presents with an urgent or emergent condition necessitating treatment to prevent or eliminate infection or to preserve the structure and function of teeth or orofacial hard and soft tissues, the weighing of the dentist’s competing ethical obligations may result in moving forward with the treatment of the patient.